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Brian W. Pence, PhD MPH Associate Professor of Community and Family Medicine and Global Health Duke University June 4, 2012
Changes in HIV Providers’ Management of Depression after
Integration of Treatment Support into Clinical Care
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Thank you to…
Abstract lead author Kiana Bess
SLAM DUNC Study Team:
Duke: Julie Adams; Jordan Akerley; Kiana Bess; Jacob Kirkorowics; Kathryn Schley; Nathan Thielman; Quinn Williams; Abigail Zeveloff
UAB: Michael Mugavero; Teena McGuinness; Riddhi Modi; James Raper; James Willig: Anne Zinski
UNC: E. Byrd Quinlivan; Malaika Edwards; Bradley Gaynes; Amy Heine; Tiphany Jackson; Julie O’Donnell; Katya Roytburd
Funding: NIMH; NINR
Duke, UNC & UAB HIV Clinics and patients
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The “HIV Treatment Cascade”
Gardner et al. CID 2011;52:793-800.
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Depression and the HIV treatment continuum
HIV
Infection
HIV
diagnosis
Engagement
and retention
in care
ART
initiation
Adherence
and virologic
suppression
Depression inversely associated with…
Pence et al. AIDS 2012;26(5):656-8
Some evidence that depression treatment can improve ARV
adherence and HIV clinical outcomes.
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The depression treatment continuum
Pence et al. AIDS 2012;26(5):656-8
Prevalent
depression
Clinical
recognition
Initiation of
treatment
Adequacy
of
treatment
Remission
of
depression
~50% of cases of
depression go
unrecognized in HIV
clinical care
~50% of those
recognized
never start
treatment
• Counseling requires a minimum contact
intensity.
• Pharmacotherapy requires aggressive dose
adjustment based on response.
• Perhaps one-third of those being treated are
receiving adequate treatment.
If adequate treatment
is provided, response
rates are high
(~70%).
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The “Depression Treatment Cascade” for HIV Patients
0%
20%
40%
60%
80%
100%
Of p
reva
lent c
ases…
Rec
ognized
clinica
lly
Any tre
atment
Adequate
trea
tment
Achie
ved re
miss
ion
Screening
Depression Care
Manager support
Goal:
Pence et al. AIDS 2012;26(5):656-8
| 95% Bayesian Credible Interval
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SLAM DUNC Study
Strategies to Link Antidepressant and Antiretroviral Management at Duke, UAB, and UNC
NIMH-funded R01, 2009-2014
Randomized controlled trial to test the effect of depression treatment on ARV adherence
Sites: HIV clinics at 3 academic medical centers
Pence et al. Contemporary Clinical Trials 2012; 33(4):828-38
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SLAM DUNC Study
Population: HIV clinic attendees with current major depression
Intervention: Measurement-Based Care depression treatment
Depression Care Managers provide decision support to HIV providers for antidepressant prescription and management
Comparison: Usual care
Outcome: ARV adherence Pence et al. Contemporary Clinical Trials 2012; 33(4):828-38
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Aim of this presentation
Does Depression Care Manager’s provision
of decision support for intervention-arm study
participants change HIV providers’
depression management practices for all
patients?
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Methods
Semi-structured in-person interviews with HIV providers
Before study launch
One year after study launch
Topics
Perception of prevalence of depression and depression treatment in caseload
Confidence treating depression
Specific depression treatment practices
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Methods
9 “best-practices” principles of depression treatment
defined from national guidelines
American Psychiatric Association* (for all patients)
NY State Dept of Health** (for HIV patients)
Providers’ self-reported practices compared to best-
practices principles and assigned a numeric score
reflecting quality relative to each principle
Summary best-practices score created using factor
analysis from item-specific scores * American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive
Disorder, Third Ed. Washington, DC: American Psychiatric Association Press; 2010.
** New York State Department of Health. Depression and mania in patients with HIV/AIDS. New York: New
York State Department of Health, 2010.
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Best-Practices Principles
1. Routine screening with standardized measure
2. Assess need for treatment based on severity
3. Base treatment choice on history and severity
4. Adjust antidepressant starting dose for ARV interaction
5. Follow-up new antidepressant prescription in 4 weeks
6. Assess effectiveness with standardized symptom severity
measure
7. Increase dose based on symptom severity and drug
tolerability
8. Utilize full FDA dosing range
9. Switch antidepressants based on formal assessment of
response, tolerability, and adequacy of trial
Screening
Initiation
Management
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Participants (n=41* with baseline and 1-year follow-up interviews)
Baseline Characteristic N (%) or Median (IQR)
Clinical training
MD-Attending
MD-Fellow
Nurse Practitioner
Physician Assistant
21 (51%)
13 (32%)
3 (7%)
4 (10%)
Clinical effort
% clinical effort on HIV care
30% (20-50%)
80% (60-95%)
Years providing HIV care
<5 years providing HIV care
9 (3-20)
15 (37%)
Very or extremely confident…
Prescribing an initial antidepressant
Switching or augmenting antidepressants
Depression treatment is part of role
25 (63%)
5 (13%)
29 (71%)
* All providers were interviewed at baseline (n=48). At one year, 3 MD-fellows had left; 41 of 45 remaining providers
completed the one-year interview.
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Baseline indicators of depression treatment quality
Bess et al. IAPAC 2011 abstract # 70029.
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Change in self-reported depression treatment practices after 1 year
Baseline 1 year
+37% *
-4%
-14%
+16%
+2%
+13%
-29% *
+22%
-6%
* p < 0.05
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Depression treatment best-practices summary score
5.7
(95% CI :4.9-6.4)
5.9
(95% CI :5.3-6.6)
p > 0.05
Mo
re g
uid
elin
e-
co
nco
rdan
t p
ractice
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“How has your depression treatment practice changed in the past year?”
Open-ended question
Most common response: Provision of routine screening has
raised awareness of depression
and likelihood of discussing depression during clinical
encounter
Next most common response: Practice has not changed
Rare responses: Concrete practice changes
Follow up sooner after starting AD (n=1)
More likely to increase AD dose (n=3)
More likely to change AD (n=1)
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“How has your depression treatment practice changed in the past year?”
“[I am] more comfortable addressing [depression] and
providing treatment with the care manager.”
“I didn’t feel it was my role at all … as a physician assistant
[and] in Infectious Diseases … I didn’t feel that the
physicians really thought it was much within their scope
either … but now there is more support, I have learned more
about the drugs, [and] I’m feeling more able.”
“I haven’t changed my practice, other than that I listen to
you guys.”
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Interpretation
Providers have responded very positively to the
provision of routine depression screening in clinic
After 1 year of Depression Care Manager decision
support for intervention patients, providers report
relatively little change in practices related to the
initiation or management of antidepressant treatment
in all patients (without DCM support)
In contrast, adherence to guidelines in intervention
patients with direct DCM support is very high
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Role of Depression Care Manager
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Interpretation
Presence of study has raised awareness but has not
changed ongoing depression management practices
Supports need for measurement-based depression
treatment decision support for all patients
No evidence of contamination (decision support
around best-practices depression treatment appears
not to have generalized beyond intervention patients
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Limitations
Self-reported practices
Providers may have “learned the right answer” after
1 year without having changed practice
Caution should be used in interpreting numeric
scores derived from qualitative data
Sites are academic medical centers with research-
oriented clinicians – practices may differ elsewhere
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Strengths
Response rate: >90% of HIV providers at 2 large
academic medical centers
Detailed qualitative assessment of provider
practices
Very little published data on depression treatment
practices of HIV providers
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Is this a fair expectation of HIV providers?
High burden and negative consequences of
depression
Rise of “medical home” model of care
Availability of evidence-based decision support
models (Measurement-Based Care)
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Depression treatment summary score, by clinical training
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Depression treatment summary score, by clinical training
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Depression treatment summary score, by years of clinical experience
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Depression treatment summary score, by years of clinical experience